Current Allergy and Asthma Reports (2020) 20: 36

https://doi.org/10.1007/s11882-020-00927-3

TELEMEDICINE AND TECHNOLOGY (J PORTNOY, SECTION EDITOR)

Wearable Technology and How This Can Be Implemented

into Clinical Practice
Justin Greiwe 1,2 & Sharmilee M. Nyenhuis 3,4

Published online: 6 June 2020

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review Our day-to-day life is saturated with health data that was previously out of reach. Over the last decade, new
devices and fitness technology companies are attempting to tap into this data, uncovering a treasure trove of useful information
that, when applied correctly, has the potential to revolutionize the way we approach healthcare and chronic conditions like
asthma, especially in the wake of the COVID-19 pandemic.
Recent Findings By harnessing exciting developments in personalization, digitization, wellness, and patient engagement, care
providers can improve health outcomes for our patients in a way we have never been able to do in the past. While new
technologies to capture individual health metrics are everywhere, how can we use this information to make a real difference in
our patients’ lives? Navigating the complicated landscape of personal wearable devices, asthma inhaler sensors, and exercise
apps can be daunting to even the most tech savvy physician.
Summary This manuscript will give you the tools necessary to make lasting changes in your patients’ lives by exposing them to a
world of usable, affordable, and relatable health technology that resonates with their personal fitness and wellness goals. These
tools will be even more important post-COVID-19, as the landscape of clinical outpatient care changes from mainly in-person
visits to a greater reliance on telemedicine and remote monitoring.

Keywords Telemedicine . Wearable devices . Personalized healthcare devices . Remote monitoring . COVID-19 . Connected
health

Introduction is likely to change drastically. This pandemic is a big wake-up

As our world has become upended with the arrival of COVID-
19, the way in which healthcare will be provided in the future
This article is part of the Topical Collection on Telemedicine and
Technology
* Justin Greiwe
jcgreiwe@gmail.com
1 tients and the states followed suit for Medicaid patients.
Bernstein Allergy Group, Inc, 8444 Winton Road,
Cincinnati, OH 45231, USA
2 healthcare providers increased flexibility to provide care for
Division of Immunology/Allergy Section, Department of Internal
Medicine, The University of Cincinnati College of Medicine,
Cincinnati, OH, USA
3
Division of Pulmonary, Critical Care, Sleep and Allergy, Department
of Medicine, University of Illinois at Chicago, Chicago, IL, USA
4
Center for Dissemination and Implementation Science, Department
of Medicine, University of Illinois at Chicago, Chicago, IL, USA
call for limiting in-person visits, especially during the flu sea-
son that put vulnerable patients at undo risk coming into the
office for routine care. We have had the technology to perform
telemedicine visits for years, but patients’ hesitancy and poor
insurance reimbursement have always been barriers for wide-
spread acceptance. In the wake of the COVID-19 pandemic,
most primary care and specialty offices transitioned to a
telemedicine-focused approach within a matter of days to
weeks. In response, the Centers for Medicare & Medicaid
Services (CMS) relaxed many requirements for Medicare pa-
Insurance companies also loosened restrictions giving
their patients from the comfort and safety of their own homes.
2020 will be the ultimate testing ground for various telehealth
services and remote monitoring applications, and it is the hope
of the authors that recent changes in access and reimburse-
ment will remain in place permanently. To meet the needs of
this growing market, new technologies including wearable
36 Page 2 of 10
devices will play an important role in providing real-time data
to objectively monitor patients at home. These devices will be
especially important for improving the health and control of
chronically ill patients and for those with conditions like asth-
ma, COPD, diabetes, and cardiovascular disease. The focus of
this paper revolves around wearable devices for asthma, but
can be applied for any chronic condition. If these home de-
vices can provide usable data in a reliable, cheap, and easy-to-
use format, then the need for in-person visits in the future will
be drastically reduced.
Connected Health
Innovations in personalized health technology provide a
unique opportunity to develop connected healthcare models
that are built around the patients’ individual needs. The term
connected health describes the use of a variety of technologies
to inform and aid healthcare delivery in a data-driven manner
with the individual at the center.7 It covers a broad domain,
including digital, mobile health, and telehealth, and ensures all
stakeholders are connected with data that is accurate and time-
ly [1]. An integrative connected health model can also offer
social support through online forums or networks where users
are able to interact with peers with similar healthcare condi-
tions or goals helping to further enhance patient experience
and improve adherence.
Commercial weight loss programs like WW (formerly
Weight Watchers) was one of the first large-scale pro-
grams to take advantage of social support networks to
motivate their clients and make them accountable to other
people. A 2005 systematic review of commercial and pro-
prietary weight loss programs’ efficacy concluded that
WW was the only program with demonstrated efficacy in
achieving modest weight loss based on results from 3 ran-
domized controlled trials (RCTs), and their unique social
approach likely contributed to its success [2]. A recently
published systematic review found relatively strong evi-
dence that greater social support, self-efficacy, and self-
motivation can predict higher adherence to home-based
therapies [3]. There is enough data to suggest that social
support networks improve adherence to fitness, weight
loss, and home-based therapies that healthcare providers
should be actively curating a wider support network for
their patients [4–6]. Wearable devices and associated apps
take social connectivity to the next level and provided
unparalleled access to support networks that have the po-
tential to further encourage adherence to fitness and health
regimens. Promising results have already been reported
with the use of apps to improve adherence and outcomes
in various healthcare scenarios including weight loss,
smoking cessation, diabetic management, and home exer-
cise programs [7–11].
Curr Allergy Asthma Rep (2020) 20: 36
The First Wave of Wearable Devices: Activity
Trackers
The concepts of wellness and mindfulness have become an
increasing part of the public health discussion as there seems
to be a growing appreciation for a more holistic approach to
fitness and well-being. With the advent of more advanced
wearable technology like fitness trackers and smartwatches
starting in 2014, consumers are no longer content with just
tracking their weight loss goals or step count. Personalized
healthcare devices arm users with snapshots of their activity
and recovery data and allow them to track advanced perfor-
mance metrics including step tracking, heart rate, body fat per-
centage, sleep quality, stress levels, menstrual cycle, and fertil-
ity windows. As this data becomes more accessible, consumers
are discovering that overall health is the sum of all the small
choices you make each day: what you eat, how much you
move, how much you sleep, etc. Having fitness and weight loss
goals is an important first step, but converting that enthusiasm
to actual gym time and change in habits has always been the
rate limiting step. That is where innovative fitness startups and
fitness technology companies are focusing their attention: get-
ting people excited about working out, offering unparalleled
convenience, and keeping members engaged long-term by uti-
lizing the latest in technology and social media. Since 2014, the
use of commercial wearable devices has doubled. Currently,
19% of Americans use a wearable fitness tracker (e.g., Fitbit,
Apple Watch) with sales projected to double by 2022, becom-
ing a $27 billion+ market [12, 13].
Wearable Devices that Promote Health
and Fitness
As more and more patients use wearable devices and
smartphone apps to track their personal health data, how can
this information be used in a meaningful way? Fitness tech-
nology companies like Fitbit and Apple Health are leveraging
insights from over 10 years of activity, exercise, and sleep data
to better inform future applications and provide behavior
change techniques and insights to their users. Apple recently
announced that customers in the USA can enroll in three land-
mark health studies: the Apple Women’s Health Study, the
Apple Heart and Movement Study, and the Apple Hearing
Study. Conducted in partnership with leading academic and
research institutions like the World Health Organization, these
multi-year longitudinal studies are leveraging the ubiquity of
Apple products to provide a treasure trove of user data to
inform potential medical discoveries that could improve
healthcare for all [14].
Wearable devices themselves can provide crude feedback
like reminders to move or stand which prompts users to take
more steps per hour or stand more frequently. For additional
Curr Allergy Asthma Rep (2020) 20: 36
charges, some devices can provide more detailed personal
wellness reports, offering actionable guidance and coaching
to help users achieve their health and fitness goals. Some
companies like Fitbit are taking it a step further and offering
personal, one-on-one coaching services for weight loss and
diabetes control providing users with a personalized plans
and direct support from their team of certified health and well-
ness coaches. A small sampling of highly rated fitness and
nutrition apps are included in Table 1.
The ultimate goal with these devices and apps is to provide
real-time feedback to patients so that they actually see data
that illustrates how destructive behaviors impact them physi-
cally, providing additional motivation to more proactively
manage their health. The more the patient understands about
their personal health, the more empowered they will be to
make meaningful behavioral changes. Healthcare providers
need to be able to access and interpret personalized health
data, as well as distill it into usable teaching points. In the
past, physicians often took an authoritarian approach to health
and fitness education which did little to encourage active par-
ticipation by the patient. By employing a patient-centered ap-
proach utilizing data gleaned from wearable devices,
healthcare providers have an opportunity to work in concert
with patients to impart measurable skills and behaviors in a
real and tangible way with the ability to track this progress
over time. When patients are included in a collaborative and
patient-centered discussion about their health and well-being,
compliance and satisfaction rates improve, leading to a more
effective doctor-patient relationship [15–17]. It is important to
note that these devices are still in their infancy, and the accu-
racy and validity of the data still need to be strengthened in
order to provide the best medical advice.
Wearable Devices in Asthma
Most of the wearable fitness device research to date has fo-
cused in diseases associated with low levels of physical activ-
ity, namely cardiovascular disease, diabetes, and cancer. Few
have focused on asthma and of the studies conducted in asth-
ma populations, all have honed in on the use of Fitbit-derived
sleep measures (i.e., sleep quality). Castner et al. used the
Fitbit Charge™ to validate sleep measures in women with
asthma [18••]. The sleep measures collected by the Fitbit were
compared with Actigraph GT3X +, a well-known and validat-
ed device to collect sleep measures [19, 20]. The Fitbit device
tended to overestimate sleep efficiency and underestimate
wake counts compared with actigraphy. Two additional stud-
ies were conducted in pediatric populations and focused on
correlating Fitbit-derived sleep measures to patient-reported
outcomes such as asthma control and asthma impact [21,
22]. Bian and colleagues assessed the association between
self-reported asthma impact and Fitbit-derived sleep quality
Page 3 of 10 36
(the ratio of minutes asleep to minutes in bed) and physical
activity measures (daily minutes of moderate and vigorous
activity) in adolescents with asthma [21]. Fitbit-derived sleep
quality was moderately correlated with Patient-Reported
Outcomes Measurement Information System (PROMIS)
sleep disturbance score (r = − 0.31, P = 0.01) and had a weak
but significant correlation with the PROMIS pediatric asthma
impact score (average r = − 0.18, P = 0.02). Fitbit-derived
physical activity levels were not associated with PROMIS
pediatric asthma impact (r = 0.04, P = 0.62). These findings
suggest that measurement of sleep quality, using the Fitbit
device, may help develop personalized asthma management
strategies for children and their caregivers in real time. The
final study measured several mobile metrics of asthma includ-
ing physical activity and sleep using Fitbits, forced expiratory
volume in 1 s and peak expiratory flow, indoor air quality
using Foobot (https://foobot.io/), and a mobile app that
collected information on asthma control (symptoms,
physical limitations due to asthma, nighttime awakenings,
and medication intake) [22]. These metrics were used
together to digitally phenotype children with asthma and
provide a better measure of the patient’s asthma control to
their clinician when compared with the Asthma Control Test
scores taken infrequently during clinic visits. Additional work
using this ecological metric of asthma control is needed and
may be used in the future to generate insights on the
relationship between a patient’s asthma symptoms and
triggers across different seasons [23].
Acoustic monitoring is another type of wearable devices
that has been studied in asthma. Breathing sound measured by
microphones over human skin can detect breathing patterns
(respiratory rate, flow rate, tidal volume) and symptoms that
may be due to asthma (wheeze, cough). Moreover, chest
movement signals can be acquired using an accelerometer or
belt-shaped device [24, 25]. Boner et al. measured the noctur-
nal wheeze in children with asthma using an acoustic respira-
tory monitor. They found that among children with apparently
well-controlled asthma, 57% had considerable amounts of
night wheezing that was unrelated to conventional measures
of lung function [26]. The use of these continual wearable
monitoring systems is still a developing field that needs fur-
ther study on its clinical impact.
Use of Electronic Monitoring Devices
in Asthma
Electronic monitoring devices (EMDs) in asthma are increas-
ingly more common since they provide objective data and are
not biased by patient self-report. The majority of the currently
available EMDs focus on addressing medication adherence,
with a limited few focusing on sleep monitoring and identify-
ing asthma triggers. The devices measuring adherence use a
36 Page 4 of 10 Curr Allergy Asthma Rep (2020) 20: 36

Table 1 Top rated fitness and nutrition apps

App Supporting devices Cost structure Details

For all-around healthy

lifestyle
8fit iOS, Android Free; $59.99 per year; $44.99 On-demand workouts and meal planning for people
per half-year; $19.99 per who like a lot of guidance, suggestions, reminders,
month for meal plans and and instructions. Provides realistic assessment of
more workouts how hard or easy it will be to reach your health and
fitness goals.

Yoga
Asana Rebel iOS, Android $39.99 for 3 months; $58.99 Yoga-inspired fitness that has guided yoga flows
for 12 months alongside regular workouts. Input goals, track
progress, and choose classes based on experience
level.
Yoga Wake Up iOS, Android $10 per month Offers different audio yoga and meditation sequences
that are designed to start in bed and end with you on
your feet.
Alo Moves iOS, Android $20 per month Has over 2000 videos organized into 200 plans and
over 500 single classes taught by the top names in
yoga.
YogaGlo iOS, Android $18 per month Offers more than 3800 yoga workouts and guided
mediation classes.

On-demand workouts
Peloton Digital iOS, Android $20 per month Access live-streamed classes to use on any bike or
treadmill or try one of their boot camp, strength, or
outdoor classes.
Fitbit Coach iOS, Android Free; $9.99 per month or Takes users daily Fitbit activity data to recommend
$79.99 per year for exercises and personalized fitness feedback. Large
Premium database of workout videos with step-by-step direc-
tions and tips. Compatible with Fitbit Radio.
Nike Training Club iOS, Android Free; $14.99 per month or Has classic short sessions but includes workout
$119.99 per year for routines that are 30, 45, or even 60 min long. A
Premium Premium account also comes with programs led by
trainers and nutrition and wellness guidance.
Sworkit iOS, Android $10 per month Custom no-equipment training plans, complete with
guided videos for each workout ranging from 5 to
60 min.
Users can also connect with personal trainers to ask
questions and get expert advice.
Aaptiv iOS, Android $15 per month Audio classes taught by trainers guiding users through
a fitness studio-style session. Over 2500 workouts in
cycling, yoga, strength training, stretching, elliptical
workouts, and more. Also comes with full marathon,
half marathon, 10K, and 5K training programs.

Fitness tracking
Strava iOS, Android, Web Free; $7.99 per month or Users can compete against themselves or others who
$59.99 per year have run, biked, or swam the same routes. The app
uses phone/watches GPS to track where users go and
how fast then compares with other users creating a
leaderboard.
Map My Fitness iOS, Android Free; $5.99 per month or Recommended for those just getting started on a fitness
$29.99 per year for MVP journey. Has hundreds of activities you can track,
everything from vacuuming to rock climbing
motivating user to keep a more active lifestyle.
Consolidates data from various fitness trackers or
apps such Fitbit.
Curr Allergy Asthma Rep (2020) 20: 36 Page 5 of 10 36

Table 1 (continued)

App Supporting devices Cost structure Details

Charity Miles iOS, Android Free Motivates by donating money to charity for every mile
users run, walk, or bicycle. Supports a variety of
nonprofit organizations, such as ASPCA, Habitat for
Humanity, St. Jude Children’s Hospital, UNICEF,
Save the Children, and the Wounded Warrior
Project.

Nutrition-Tracking
MyFitnessPal iOS, Android Free; $9.99 per month or Calorie counting app that also figures out how many
$49.99 per year for calories users should eat to gain, lose, or maintain
Premium weight. Consolidates everything users eat and drink,
plus all their activities to calculate calories consumed
against calories burned. It also has tools for tracking
weight and other body changes over time. It has the
largest database of foods and is the best food logging
app on the market.
Noom iOS, Android $59 per month, $199 per year Complete weight loss program with daily interactive
(additional pricing options content, a personal goal coach, and plenty of content
available) to help users master the psychology involved with
changing their relationships to food.
MyPlate iOS, Android, Web Free; $9.99 per month, $30 All-in-one fitness app, combining calorie counting,
for six months, or $44.99 weight management, recipes, and workouts. Users
per year for Gold look up and record everything they eat and can see a
nutritional analysis of macronutrient intake for free
(requires paid subscription in MyFitnessPal).
WW Digital (formally iOS, Android, Web $23.99 per month or $219.99 Highly supportive community and app that focuses
WeightWatchers) per year more on personalization and overall health rather
than weight loss alone. Users do not have to attend
meetings or meet with a counselor (although this is
an option for an added fee). Monitors food intake
with SmartPoints rather than counting calories or fat.

Mindfulness and meditation

Calm iOS, Android $14.99 per month or $69.99 Guided mindfulness meditation that initially offers a “7
per year Days of Calm” course which introduces users to
mindfulness meditation, as well as some guided and
unguided meditation sessions. Paid users have
access to more multi-day courses, a “Daily Calm”
course, and many, many more guided meditations.
Headspace iOS, Android $12.99 per month or $69.99 Guided meditation for health issues, emotions,
per year challenges, and productivity. There are even “SOS”
sessions for some of the more stressful times in life.
Recently added free content called Weathering the
Storm for those struggling with the emotional effects
of COVID-19.
The Mindfulness App iOS, Android $9.99 per month or $59.99 Starts with a 5-day introduction to mindfulness along
per year with guided meditations to get you familiar with
meditating. With subscription choose guided or si-
lent meditation sessions for challenges, travel, sleep,
relationships, stress relief, emotions, body
awareness, focus, and relationships.

*The authors are aware of the transient nature of fitness, nutrition, and lifestyle apps and understand that the recommendations provided at the time of this
publication might not be available in the future

variety of approaches from recording audio during inhaler use, spirometry measures. These devices are paired with mobile
using time and date to detect medication use and capturing applications (Apps) on smartphones which can provide the
Table 2 Current and emerging technologies in asthma
36 Page 6 of 10

Technology Measures Outcomes in asthma studies Comments

Wearable technology
− Fitbit™
− Apple™ Watch
Electronic monitoring devices
(e.g., inhaler sensors ± digital
health platform)
Mobile-based applications
Fitbit: heart rate (available on most but not all
models), steps/day, physical activity (light,
moderate and vigorous), sedentary time,
sleep efficiency, wake counts
Apple Watch: heart rate, EKG, steps/day,
physical activity (light, moderate and
vigorous), sedentary time
Digihaler™:
− Inhaler time of inhaler use, peak inspiratory
flow rate (PIFR), time to PIFR, inhalation
volume and duration.
Propeller Health System:
− Inhaler sensor: date, time and number of
doses taken
− Asthma Health Platform App: Location of
inhaler use using phone GPS, current
weather/pollen counts/air pollution and
self-report asthma symptoms/triggers
Hailie™ solution:
− Inhaler sensor: date, time, number of inhaler
actuations and missed doses
− Hailie™ App: medication adherence, daily
medication reminders
Inhaler compliance assessment device:
Time of dose, inhaler technique errors
Self-monitoring of:
− Asthma symptoms
− Triggers
− Medication use
− Fitbit overestimated sleep efficiency and
underestimated wake counts compared with
actigraphy.18
− Fitbit-derived sleep quality correlated with
PROMIS pediatric asthma impact score.21
− Greater asthma control31,38–39 and
symptom-free days33
− Reduction in daily symptoms31, rescue
medication use29,32–33, and
exacerbations34,38–39
− Improved medication adherence36–40
− High patient acceptability of device and
digital health platform36–37.
-Improvements in asthma control though
low-quality evidence45
-Improvements in asthma control in five
studies, lung function in two studies and
quality of life in three studies46
Corresponding Apps: Apple Watch App on iPhone,
Fitbit App on iPhone and Android
Pros: portable; commercially available; may be
useful when used with other measures such as air
quality, lung function and asthma symptoms to
digitally phenotype asthma patients
Cons: No sleep data available on Apple Watch
without 3rd party App
Data sharing: Data does not sync to EMR directly
but patient can access file and send to provider
via mail, secure email, or patient portal.
Corresponding Apps: Digihaler™, Propeller
Health, Hailie™. Web-based platform also
available for Propeller Health, Hailie™ solution.
Pros: portable, high acceptability among patients,
improvements in asthma control in those with a
digital health platform (e.g., Propeller Health,
Hailie™ solution).
Cons: Additional efficacy studies of the devices are
needed, cost of devices are not always covered
by insurance reimbursement
Data sharing: Provider platform available to share
results (e.g. Digihaler™, Propeller Health,
Hailie™ solution), patients may share data from
Digihaler™ also via file share.
Pros: Acceptable and feasible to use
Cons: Vary in quality; data are self-reported, most
apps have not been validated; risk of loss of
privacy of health information
Data sharing: Vary in ability to share with provider,
most are up to user to share with provider
Curr Allergy Asthma Rep (2020) 20: 36
Curr Allergy Asthma Rep (2020) 20: 36
patient with audiovisual reminders for taking medications,
correlate medication use with environmental exposures (i.e.,
weather, ozone, pollution) using smartphone GPS coordinates
and feedback on proper inhaler use. A summary of some of
the current and emerging technologies in the asthma space is
provided in Table 2.
Teva’s Digihaler™ has been FDA approved for use with
ProAir® (albuterol sulfate 117 mcg), AirDuo® (fluticasone
propionate and salmeterol), and ArmonAir® (fluticasone pro-
pionate) inhalers. The Digihaler™ contains built-in sensors
that records inhalation data with timestamps. The inhalation
data includes parameters that are important for assessing in-
haler technique including peak inspiratory flow rate and inha-
lation duration [27]. The device is connected via Bluetooth®
technology to a companion App that provides information on
inhaler use to the patient. While to date, the efficacy of
Digihalers has not been evaluated; one pilot study has shown
its ability to predict exacerbations [28]. Adults with
exacerbation-prone asthma (n = 360) used the ProAir®
Digihaler™ for 12 weeks. The Digihaler™ was able to predict
asthma exacerbations (defined as need for oral corticosteroids)
with an area under the receiver operating characteristic curve
of 0.75. The most predictive factor was the average number of
albuterol inhalations per day during a period of 5 days before
an exacerbation. Further developments of the model in larger
populations are needed to determine the efficacy of the
Digihaler™ to predict exacerbations.
Propeller Health has developed a system which includes
a sensor that can attach to both rescue and controller inhalers
and an Asthma Health Platform [29]. The inhaler sensor
collects date and time of inhaler use and number of puffs
taken. This data is transferred via Bluetooth® technology to
the Asthma Health Platform on a mobile device and can be
matched with GPS coordinates obtained from the mobile
device. The Asthma Health Platform can also be used to
record asthma symptoms and triggers which integrates with
other data streams such as weather, pollen counts, and pol-
lution. The Propeller Health System is one of the most stud-
ied to date. A 4-month pilot study conducted in 30 individ-
uals showed when the device and app were used along with
weekly feedback, participants had an improvement in asth-
ma control and a decline in day-to-day asthma symptoms
[30]. The effectiveness of Propeller Health System on res-
cue inhaler has also been examined [31••]. In a study of 495
patients, all patients received the Propeller Health System
but only 250 received sensor-based feedback. The authors
found a decrease in mean daily rescue medication use in
those receiving sensor-based feedback (0.19 vs. 0.25 in con-
trol arm) which was more pronounced in patients with un-
controlled asthma at baseline. These findings were con-
firmed in another study of 120 participants with a decrease
in rescue medication use by 39% and an increase in
symptom-free days by 12% [32]. Propeller Health has also
Page 7 of 10 36
developed a provider-facing web interface (portal) that al-
lows providers and their staff to view patient medication use
and asthma control status. This is available to providers that
enroll their patients with the Propeller Health System but
can be integrated into existing EMR systems to allow for
data sharing among providers. Merchant et al. evaluated this
enhanced Propeller Health System and found a decrease in
asthma-related emergency department visits and hospitali-
zations [33].
The Hailie™ solution (previously known as
SmartInhaler™ platform) is a system of medication sensors
(e.g., SmartTrack™, SmartTouch™, SmartTouch AV™,
SmartTurbo™; http://www.smartinhaler.com/devices/) that
wrap around existing inhalers and automatically sends usage
data to a patient’s smartphone [34]. The sensors record the
date and time of actuations, the total number of actuations
used, and missed doses. The device pairs with the Hailie™
App and enables the patient and healthcare professionals to
track medication adherence, set daily reminders, and discover
insights into their medication usage. The SmartInhaler™
sensors have been studied extensively and have
demonstrated high user acceptability as well as efficacy in
increasing medication adherence [35, 36]. Five randomized
controlled trials using the SmartInhaler™ have been
conducted in the UK, Australia, and New Zealand, including
a total of 589 adults and children with asthma in a community
setting [35–39]. The authors of these studies conclude that
SmartInhaler™ devices were more effective than standard
care in improving adherence to asthma medication. Two of
the studies showed significant improvement in clinical
outcomes (e.g., asthma exacerbations, asthma control, and
healthcare utilization) [37, 38].
The Inhaler Compliance Assessment (INCA) device
uses time-stamped audio recordings of inhaler use to as-
sess not only inhaler adherence but also inhaler technique
(http://www.tueohealth.com/). Specifically, it can assess
proper inhaler technique by measuring a failure to prime
the inhaler, inadequate inspiratory flow, and dose
dumping. This information can be used to determine if
medication was not properly delivered due to inhaler
technique errors (attempted adherence) or missed/late
medication doses. In one study of 184 people with chron-
ic obstructive pulmonary disease, the INCA device was
used to assess controller inhaler adherence [40]. The mean
rate of attempted adherence was 58.7%, whereas actual
adherence (proper timing and technique) was only 23%.
Only 7% of participants had actual adherence above 80%,
underscoring the importance of addressing proper inhaler
technique. Currently, there is no mobile app for the INCA
tool and the data must be downloaded onto a computer for
analysis. Additional studies are currently being conducted
using an INCA App to assess its ability to improve asth-
ma outcomes.
36 Page 8 of 10
Tueo Health, which was acquired by Apple in 2019, devel-
oped a passive EMD to help parents monitor nighttime asthma
symptoms in children. Using commercial breathing sensors
placed under the mattress, the device can passively measure
key physiologic parameters during sleep (http://www.
tueohealth.com/). An asthma control score is then calculated
from the physiologic data and available for the patient to view
through a mobile app. The score gives direct indication of
their asthma control status based on their provider-issued asth-
ma action plan and recommends evidence-based steps to man-
age asthma. Such steps include reminders to avoid known
triggers, refill a prescription, or make an appointment to see
their healthcare provider.
Use of Mobile Apps in Asthma
As with wearable devices, the use of health apps on phones
and tablets has rapidly been increasing [13]. There are a large
number of asthma-related apps with well over 500 reported in
2019 [41••]. The mobile apps range from providing health
education, symptom tracking, environmental alerts, and med-
ication reminders. A review conducted in 2015 selected 209
English asthma-related apps that were available in Google
Play and/or Apple Store [42]. The majority (52%) of the apps
evaluated were teaching and training information for patients,
with 39% based on alternative treatments, such as yoga, acu-
pressure, and breathing exercises; 22% helped users to mon-
itor symptoms and medication adherence; 18% provided med-
ical reference information for providers; 6% provided air qual-
ity information; and 2% served as social forums for patients
with asthma.
Despite the great number of currently available mobile
apps for asthma, few effectiveness evaluations have been con-
ducted. In 2013, Marcano and colleagues conducted a
Cochrane review on mobile apps for asthma self-manage-
ment. Only two randomized controlled trials (RCTs) fit the
review criteria and assessed efficacy of the apps on asthma
outcomes such as asthma control, asthma quality of life, and
healthcare utilization [43]. Both RCTs (n = 408) evaluated the
effect of a mobile phone-based asthma self-management in-
tervention on asthma control by comparing it with traditional,
paper-based asthma self-management. Overall, the results
were inconclusive, as the evidence was low quality
(GRADE) and attrition bias plus other sources of bias were
found. In 2017, another systematic review assessed asthma
self-management using mHealth apps [44]. The authors found
that mHealth apps improved asthma control in five studies,
lung function in two studies, and quality of life in three stud-
ies. There was no significant impact on economic outcomes
such as hospitalization rates.
While there is preliminary evidence on the efficacy of asth-
ma self-management mobile apps to improve asthma control
Curr Allergy Asthma Rep (2020) 20: 36
and quality of life, the mechanisms have not been well stud-
ied. Ramsey and colleagues reviewed the content and quality
of mHealth asthma self-management apps [45••]. The mobile
apps were identified through systematic searches of the Apple
and Google Play stores and then coded to evaluate the inclu-
sion of evidence-based behavior change techniques (BCTs).
Examples of BCTs include providing information about
behavior-health link, identifying barriers to performing health
behaviors, and prompting self-monitoring of behaviors. The
quality of the apps was also rated using the Mobile App
Rating Scale (MARS) to determine app engagement, func-
tionality, aesthetics, information quality, and subjective qual-
ity. Of the twenty-three apps identified, a range of 1–11 BCTs
were used by the apps. The most commonly included BCTs
were instruction, behavior-health link, self-monitoring, feed-
back, teach to use prompts/cues, consequences, and others’
approval. Three apps used at least eight BCTs (i.e.,
AsthmaMD, Kiss myAsthma, and My Breathefree). The over-
all quality of the apps, as measured by MARS, ranged from
2.45 to 4.50 (out of a possible 5.00). Four apps had an overall
MARS quality of > 4.0 (AsthmaMD, Asthma Health
Storylines, Kiss myAsthma, and Wizdy Pets: Kids’ Asthma
Game). As it is more common for patients to ask their
healthcare providers to help them choose apps, it is important
that providers are knowledgeable about which asthma man-
agement apps are high quality and include evidence-based
components that will be successful for behavior change. To
date, Kiss myAsthma and AsthmaMD are the asthma man-
agement apps with the highest number of BCTs and quality
scores, but this area is constantly evolving.
There are some limitations to consider regarding the use of
mobile apps for asthma. The majority of commercially avail-
able asthma apps lack validation in clinical settings. Further,
the apps are not regulated or approved as medical devices and
may provide recommendations to patients that are not
evidence-based or inaccurate. Finally, there is a risk of loss
of privacy of health information for patients that use these
apps. One study showed that only 30% of the most commonly
used mHealth apps had privacy policies [46]. These policies
often required a high-level of literacy for comprehension,
were often not focused on the app itself, and were not infor-
mative for end users. Therefore, clinicians should evaluate
asthma management apps to ensure high quality and
evidenced-based information prior to recommending them
for their asthma patients.
Conclusion: a New Wave of Wearable Devices
The world and medicine as we know it are changing forever in
the wake of the repercussions of the COVD-19 pandemic.
Limiting unnecessary in-person visits, especially for at-risk
patients, and expanding the scope of what we can provide
Curr Allergy Asthma Rep (2020) 20: 36
remotely using new technological advancements should be a
priority moving forward. The future of wearable devices
seems to be headed towards continuous measurements of per-
sonal physiology to predict, prevent, or help to aid in the
diagnosis of an underlying health condition. This approach
allows frequent and continuous measurements of body func-
tions including heart rate, skin temperature, blood oxygen
levels, and physical activity. Recent studies investigating the
utility of wearable sensors indicate that the information pro-
vided by these devices is physiologically meaningful and ac-
tionable and will likely to play an important role in managing
health in the future [47]. Healthcare providers and patients
themselves can do a much better job of tracking their health
outside of regularly scheduled office visits. Currently, pro-
viders are relying on patients with chronic health conditions
to consistently self-report progress and medication compli-
ance which is inefficient and unpredictable at best. Having
access to reliable home data on a consistent basis that is rele-
vant to the patient’s specific medical condition is key to im-
proving health outcomes not only for asthma but also for all
chronic diseases. Increased utilization of health monitoring
devices by patients will likely become an important aspect
of self-care and preventive medicine moving forward. The
data provided by these devices will allow care providers to
provide patients with personalized tools and tailored solutions
to improve their health and encourage fitness and diet goals.
They may also help to enhance accurate symptom reports,
improve accuracy of diagnosis, and streamline appropriate
specialty referral when appropriate.
Compliance with Ethical Standards
Conflict of Interest Dr. Greiwe is a consultant for AstraZeneca on social
media and respiratory biologics scientific expert on the virtual advisory
board; Sanofi Grenzyme Dupixent scientific expert on the virtual adviso-
ry board; honoraria from AstraZeneca Fesenra Speakers Bureau,
Regeneron, and Sanofi Grenzyme Dupixent Speakers Bureau. Dr.
Nyenhuis is a board member of Chicago Asthma Consortium; grant from
National Institute of Health, honoraria from Sanofi, royalties from
Springer Nature and Wolters Kluwer Health.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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